Are you filling this out for yourself or someone else?

Many of our underground workers have passed away from their occupational exposures(please indicate your relation in the relevant info box at the end of this questionnaire)

Myself

Someone who has passed

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Employment Status

Currently Employed

Retired

Other

Are you currently experiencing any illness or symptoms that could be related to your occupation?

Ie: Respiratory Illneses, Cancer(s), etc

Yes

No

Unknown